**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of fifty-three (53) sampled residents (Resident #6) was treated with respect and dignity and failed to ensure the resident's right to retain and use personal possessions, including clothing. According to Resident #6, facility staff came into his/her room on 02/24/2022 and took all of his/her personal belongings to another room. Resident #6 stated he/she told staff to leave the belongings alone, and the resident refused the transfer. Resident #6 stated he/she cried and asked for his/her belongings from 02/24/2022 to 02/28/2022 until they were returned on 02/28/2022. The facility's failure to ensure staff treated residents with dignity and respect and failure to ensure a resident's right to retain and use personal belongings has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Resident Rights H5MAPL0768, undated, revealed the resident's right to retain and use personal possessions to the maximum extent that space and safety permit. Review of the facility's document, Residents' Rights for Residents in Kentucky Long-Term Care Facilities, undated, revealed residents could retain the use of their personal clothing unless it would infringe upon the right of others. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Continued review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed he/she told staff not to take his/her belongings on 02/24/2022. However, the facility removed the resident's personal possessions in an attempt to move him/her to another room against his/her wishes. The staff would not return the resident's personal belongings which resulted in the resident not being able to perform routine Activities of Daily Living (ADL). Resident #6 stated he/she was not able to change his/her clothing or perform dental care until his/her belongings were returned on 02/28/2022. Resident #6 stated he/she cried and asked for his/her belongings, from the time they were taken until they were returned. Resident #6 stated he/she was told it was the Administrator's instruction to move his/her belongings to another room. Interview with Housekeeping Staff #1, on 03/11/2022 at 9:30 AM, revealed she was told to pack Resident #6's belongings and move them to another room in the facility, on 02/24/2022. Housekeeping Staff #1 stated Resident #6 told the staff not to touch his/her belongings and stated he/she was not going to be transferred to the other room. Further interview revealed Housekeeping Staff #1 stated she informed her supervisor of the situation. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she talked with Resident #6 the same day she was informed the resident did not want to be transferred. The Housekeeping Supervisor stated she informed the Administrator of Resident #6's refusal to be transferred. Continued interview revealed the Administrator stated to go ahead and move Resident #6's belongings to the new room, and the resident could go and get his/her items if he/she wanted them. Interview with SRNA (State Registered Nurse Aide) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated the resident was tearful and kept asking for his/her belongings to be returned. Interview with LPN (Licensed Practical Nurse) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. She stated she talked with the Administrator who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator that Resident #6 wanted to speak to her. The LPN stated the Administrator never talked to Resident #6 during this timeframe. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6, nor was she able to help the resident change clothes since the resident's personal belongings were taken from the resident's room. SRNA #18 stated Resident #6 was very upset and crying, asking for his/her belongings to be returned. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, revealed Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated Resident #6 was anger and upset regarding the Administrator taking his/her personal belongings. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she did not provide direct care to Resident #6. She stated she heard that the Administrator had taken Resident #6's personal belongings and did not return them to the resident and the resident was very upset. Interview with SRNA #26, on 03/16/2022 at 4:00 PM, revealed she had just started working at the facility on 02/21/2022. SRNA #26 stated towards the end of the week, either 02/24/2022 or 02/25/2022 (Thursday or Friday), she remembered Resident #6 was supposed to be transferred to another room, but the resident refused. Interview with SRNA #16, on 03/18/2022 at 7:47 AM, revealed she worked on Thursday and Friday nights. Review of the staffing record confirmed SRNA #16 worked on the 300 Hall on 02/24/2022. Further interview revealed that she had administered medications to Resident #6 on that night. The SRNA stated that Resident #6 was very upset about his/her belongings being moved. Interview with Maintenance Technician #1, on 03/30/2022 at 4:13 PM, revealed it was one of his first days at the facility when Resident #6's belongings were moved from his/her room. He stated he had gone to the room to install a television for Resident #6's roommate, and Resident #6 was not in a good place. He stated Resident #6 was very angry and distressed. Continued interview revealed Resident #6 did not know who he was (the Maintenance Technician), but the resident just needed to tell somebody about the situation. He stated Resident #6 told him that he/she did not have any of his/her belongings, had not been able to brush his/her teeth or wash, and did not have his/her cell phone because they had been moved to another room by staff. Maintenance Technician #1 stated he went to the Social Services Director to get help for Resident #6. He stated the Social Services Director did go talk to the resident. Interview with the Director of Nursing (DON), on 03/17/2022 at 4:10 PM, revealed she was unaware of Resident #6 being without his/her belongings over the weekend. She stated at the morning meeting the next day, Friday, 02/25/2022, the topic was brought up that Resident #6 had refused to be transferred from Unit 2, but his/her belongings had already been taken to another room on Unit 1. The DON stated the Administrator stated she was going to talk to Resident #6 before having his/her belongings returned. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed Resident #6 was refusing the room transfer. She stated she was going to talk to Resident #6, on 02/24/2022, but she forgot, and when she remembered, on 02/28/2022, she had the resident's belongings returned to him/her The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with [NAME] #2 at 10:10 AM; [NAME] #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revealed they audited for care needs such: as care plans being implemented; residents being treated with dignity and respect; abuse and reporting it; as well, as rounding to ensure care needs were being met. 11. Interview with the Regional Director of Operations (RDO)/Interim Administrator and the Regional Clinical Operations Consultant, on 03/31/2022 at 9:30 AM, revealed they were in daily contact with the Medical Director who was coming weekly to the facility to discuss corrective action. Interview with the Medical Director, on 03/31/2022 at 3:03 PM, revealed he was on conference call with lawyers about corrections and met with the QA Committee with plans. The Medical Director stated he was curious about why people didn't pursue resolution at lower level first. He stated, It is a work in progress. He also stated he was going to stay on the QA Committee, coming weekly from 3:00 PM on that day for however long it was necessary. Continued interview revealed he was in daily contact with the RDO. The Medical Director stated he would review applicant names for the new Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to protect residents from abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6). The facility willfully deprived Resident #6 of his/her personal belongings, from 02/24/2022 to 02/28/2022. These belongings were necessary to attain or maintain his/her mental and psychosocial well-being necessary to avoid mental anguish or emotional distress. Resident #6 stated he/she felt this behavior was abuse, as well as staff, who described this behavior as abusive. Staff were aware Resident #6 was upset and cried during this time. However, the resident's belongings were not returned until 02/28/2022. The facility's failure to provide Resident #6 with his/her personal belongings and failure to follow their policy to ensure all residents were free from abuse and neglect has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Identification (of Abuse), dated 11/03/2017, revealed the facility identified the potential for abuse, neglect, misappropriation of property and exploitation by reviewing the daily nursing report forms, conducting nursing rounds, and routine observations. Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by the individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental, or emotional anguish. Review of the facility's document, Abuse Policy Definitions, dated 11/02/2017, revealed willful was defined as an individual acting in a deliberate way; not that the individual must have intended to inflict injury or harm. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed facility staff removed his/her belongings, including clothing, grooming/hygiene and dental supplies, on Thursday, 02/24/2022, and did not return them until the following Monday, 02/28/2022. Resident #6 stated this was done in an attempt to make him/her move to another room. The resident stated that he/she was not able to change clothes, to perform personal hygiene, and was unable to perform oral care. Resident #6 stated he/she was very upset and hurt by the facility's actions and cried the entire weekend. The resident stated he/she told the housekeeping staff not to touch his/her belongings. Resident #6 stated he/she asked repeatedly to speak to the Administrator, as well as asked daily to have his/her personal belongings returned. Resident #6 stated he/she felt this was abuse. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she felt it was abusive of the Administrator to take Resident #6's personal belongings and not return them to the resident. Interview with State Registered Nurse Aide (SRNA) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated she felt this situation was abuse by taking the resident's personal belongings. The SRNA stated Resident #6 was very upset and cried repeatedly. But SRNA #7 stated she was afraid she would have been fired if she reported the abuse. Interview with Licensed Practical Nurse (LPN) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. LPN #2 stated she talked with the Administrator, who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator Resident #6 wanted to speak to her. However, the Administrator never talked to Resident #6 during this time. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6 nor, was she able to help the resident to change clothes since the resident's personal belongings were taken from the resident's room. SRNA #18 stated she felt this was abuse, but she was afraid to report the abuse. SRNA #18 stated other staff have been fired for reporting things. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, felt it was abusive of the Administrator to remove Resident #6's personal belongings and told staff not to return them. SRNA #14 stated Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated she was afraid to report the abuse due to being fired. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she felt this was abuse and that she was aware of what constituted abuse. Interview with SRNA #11, on 03/18/2022 at 10:50 AM, and SNRA #16, on 03/18/2022 at 7:45 AM, revealed they felt taking a resident's belongings and not returning them would be considered abuse. LPN #3 stated staff were afraid to report anything due to the risk of being fired. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed Resident #6 was refusing the room transfer and was going to talk to Resident #6 on 02/24/2022 but she forgot, and when she remembered, on 02/28/2022, she had the resident's belongings returned. Further interview revealed the Adminstrator stated she had meant to go and talk to the resident on Friday, 02/25/2022, and if the resident still refused the transfer, she would have returned the resident's belongings then. When interviewed regarding Resident #6 having to go all weekend without his/her personal belongings, including hygiene and clean clothing, the Administrator then stated it would be considered abuse. When interviewed why she did not report the abuse, the Administrator stated she did not know. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with [NAME] #2 at 10:10 AM; [NAME] #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revealed they audited for care needs such: as care plans being implemented; residents being treated with dignity and respect; abuse and reporting it; as well, as rounding to ensure care needs were being met. 11. Interview with the Regional Director of Operations (RDO)/Interim Administrator and the Regional Clinical Operations Consultant, on 03/31/2022 at 9:30 AM, revealed they were in daily contact with the Medical Director who was coming weekly to the facility to discuss corrective action. Interview with the Medical Director, on 03/31/2022 at 3:03 PM, revealed he was on conference call with lawyers about corrections and met with the QA Committee with plans. The Medical Director stated he was curious about why people didn't pursue resolution at lower level first. He stated, It is a work in progress. He also stated he was going to stay on the QA Committee, coming weekly from 3:00 PM on that day for however long it was necessary. Continued interview revealed he was in daily contact with the RDO. The Medical Director stated he would review applicant names for the new Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of job descriptions, and review of the facility's policies, it was determined the facility failed to report allegations of abuse and neglect for one (1) of fifty-three (53) sampled residents (Resident #6), whose personal belongings were removed from his/her room for four (4) days causing him/her psychosocial harm. Resident #6 cried and was upset from Thursday to Monday. Staff wasn't able to provide the necessary care for the resident. The resident asked for his/her belongings to be given back. However, no one would give him/her his/her belongings. Although the resident felt this behavior was abusive and staff thought it was abuse, no one reported this as an allegation of abuse. The facility's failure to ensure staff followed the facility's policy for reporting abuse, has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Prevention - Reporting of Concerns, Incidents, and Grievances, dated 02/2004, revealed it was the policy of the facility to encourage residents, families, and staff to report concerns, incidents, and grievances without the fear of retribution. Continued review revealed the policy encouraged all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 11/02/2017, revealed it was the responsibility of the facility's employees, the facility's consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility's management. Review of the facility's policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals, dated 11/03/2017, revealed it was the policy of the facility that all suspected violations of abuse, neglect, exploitation, or mistreatment would be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Review of the facility's policy titled, Policy for Adult Protection, undated, revealed it was a policy of the facility that any employee who had reasonable cause to believe or even suspect that a resident or child had suffered abuse or neglect must report the incident immediately. Continued review revealed abuse or suspicion of abuse included rough physical treatment, abusive or disrespectful language, neglect or failure to respond to a resident's needs, or misappropriation of property. Further review revealed this reported incident must be given immediately to his/her supervisor and the Administrator or his/her designee. Review of the facility's job descriptions for Nursing Assistant, Licensed Practical Nurse, Director of Nursing, Social Services Director, and Administrator, all undated, revealed under Resident Rights, the Essential Functions were to ensure all residents were given fair and equitable treatment, the freedom of self-determination, individuality, and the respect for privacy, property, and civil rights. Review of the facility's document, In-Service Training, undated, revealed all employees received periodic in-service training relative to resident rights and the facility's abuse prevention program's policies and procedures. Continued review revealed all employees were required to attend the facility's resident rights and abuse prevention program in-service training sessions prior to having any resident contact. Further review revealed annual resident rights in-service training programs were conducted, and it was mandatory that all personnel attend such training programs. Review of the facility's inservice sign-in sheets compared to the employee roster revealed all current staff had received abuse training, at the last annual training. Further review revealed all new hires had received abuse training upon hire. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed facility staff removed his/her belongings, including clothing, grooming/hygiene and dental supplies, on Thursday, 02/24/2022, in an attempt to force him/her to move to another room. The resident's belongings were not returned until the following Monday, 02/28/2022. Resident #6 stated he/she was not able to change clothes or to perform personal hygiene, including oral care. Resident #6 stated he/she was very upset and hurt by the facility's actions and cried throughout the four (4) days. The resident stated he/she told the housekeeping staff not to touch his/her belongings. Resident #6 stated he/she asked staff repeatedly to speak to the Administrator and also asked daily to have his/her personal belongings returned. Resident #6 stated he/she felt this was abuse. Interview with the Housekeeping Supervisor, on 03/11/2022 at 10:00 AM, revealed she felt it was abusive of the Administrator to take Resident #6's personal belongings and not return them to the resident. The Housekeeping Supervisor stated she would have been fired if she had reported the abuse. Interview with State Registered Nurse Aide (SRNA) #7, on 03/15/2022 at 2:50 PM, revealed she worked with Resident #6 during the time the resident did not have his/her personal belongings. SRNA #7 stated she felt this situation was abuse by taking the resident's personal belongings. But SRNA #7 stated she was afraid she would have been fired if she reported the abuse. Interview with Licensed Practical Nurse (LPN) #2, on 03/15/2022 at 3:05 PM, revealed she worked with Resident #6 on 02/24/2022. LPN #2 stated Resident #6 was very upset about his/her belongings being taken. She stated she talked with the Administrator, who stated not to return Resident #6's belongings. LPN #2 stated she informed the Administrator that Resident #6 wanted to speak to her. However, she stated the Administrator never talked to Resident #6 during this time. Interview with SRNA #18, on 03/15/2022 at 2:25 PM, revealed she was unable to provide any care to Resident #6, nor was she able to help the resident to change clothes since the resident's personal belongings were taken from the resident's room. She stated she felt this was abuse, but she was afraid to report the abuse. SRNA #18 stated other staff had been fired for reporting things. Interview with SRNA #14, on 03/17/2022 at 4:00 PM, revealed it was abusive to remove Resident #6's personal belongings. She stated the Administrator told staff not to return them. The SRNA stated Resident #6 stated it was abuse to take his/her belongings and not return them to him/her. SRNA #14 stated she was afraid to report the abuse due to being fired. Interview with LPN #3, on 03/17/2022 at 6:15 PM, revealed she did not provide direct care to Resident #6, but had heard the Administrator had taken Resident #6's personal belongings and did not return them to the resident. LPN #3 stated she felt this was abuse. LPN #3 stated staff were afraid to report anything due to the risk of being fired. Interview with SRNA #11 and SRNA #16, on 03/18/2022 at 7:47 AM and 10:49 AM, revealed they felt taking a resident's belongings and not returning them would be considered abuse. SRNA #16 stated she was going to write her concerns regarding Resident #6 on the 24-hour nursing report, but she was afraid to report the abuse due to fear of being fired. SRNA #11 stated she did not report the abuse due to the fear of being fired. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed she was informed that Resident #6 refused the room transfer and she was going to talk to Resident #6 on 02/24/2022. Continued interview revealed she forgot to talk to the resident, and when she remembered, on 02/28/2022, she had the resident's belongings returned. When interviewed whether it was abuse or not, the Administrator stated she had meant to go and talk to the resident on Friday, 02/25/2022, and if the resident still refused the transfer, she would have returned the resident's belongings then. When interviewed regarding Resident #6 having to go all weekend without his/her personal belongings, including hygiene and clean clothing, the Administrator stated it would be considered abuse. When interviewed why she did not report the abuse, the Administrator stated, I don't know. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with [NAME] #2 at 10:10 AM; [NAME] #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RDM) and the contracted dietary Regional Manager. They stated they had training on calibrating thermometers every morning; training on the food temperatures including being sure not to touch the bottom of the pan because it was hotter than the food; and more education on the dishwasher and sanitizer. Interview with the Regional Dietary Manager (RDM), on 03/31/2022 at 10:28 AM, revealed he had been in this position just this week since Monday and had been in the kitchen daily since Friday. He stated he had provided trainings on the issues, every staff member now had their food handler permits as required. He further stated every kitchen employee had been provided job descriptions, so they knew what they were responsible for. He stated training was provided on food storage, temperatures, dating foods, use by dates for foods, temps required for cooking, and providing snacks. He further stated he would be checking in daily and be at the facility at least 2-3 days per week for the time being. 9. Observations beginning on 03/30/2022, revealed food being stored correctly in the coolers. Observations on 03/31/2022 at 11:30 AM, revealed staff recording temperatures correctly and recording them on temperature log sheets. Review of the log sheets revealed daily recording of all meals being documented. 10. Review of the facility's audit sheets, on 03/30/2022, revealed documentation of audits being performed daily. The sheets were turned into the Quality Assurance and Performance Improvement (QAPI) Committee. Interview with the Regional Director of Operations (RDO)/Interim Administrator, Admissions Coordinator (AC), Regional Nurse Consultant (RNC), and the Director of Nursing (DON), on 03/31/2022 at 9:50 AM, revealed they were meeting daily to review the audits being performed. The Department Directors/Managers were going around to perform the various audits to ensure staff compliance with the recent reeducation and training. Observations of rounds, on 03/31/2022 at 11:01 AM, with SRNA Supervisor and scheduler, revea[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, to meet the resident's highest practicable quality of life, specifically nursing and psychosocial needs, that were identified in the comprehensive assessment for two (2) of fifty-three (53) sampled residents (Residents #6 and #50). The facility deprived Resident #6 and Resident #50 of goods or services that were necessary to attain or maintain his/her highest level of practicable physical, mental, and psychosocial well-being. Review of Resident #6's care plan, dated 11/23/2021, revealed a focus of psychosocial wellbeing risk related to a new environment. Goals included the resident would have care needs met daily as measured by the resident being clean, well-groomed, and odor free. Interventions included staff assistance with dressing, hygiene, and oral and denture care daily and, as needed. However, Resident #6 stated his/her personal belongings were removed from his/her room and held without consent from 02/24/2022 through 02/28/2022. Staff was not able to provide Resident #6's daily hygiene and oral care due to lack of supplies and clean clothing. Review of Resident #50's care plan, dated 01/27/2022, revealed a goal of being free from signs and symptoms of mood decline. Interview with the resident revealed, on 02/07/2022, Resident #50 was transferred to another room without prior notification or consent. Staff removed everything off the resident's walls and his/her other belongings. Resident #50 stated that he/she felt very distraught, cried everyday, and was emotionally distressed. Continued interview revealed his/her attachment to the original room was due to having resided there with his/her spouse, who was now deceased . The facility's failure to implement the comprehensive person-centered care plans for Residents #6 and #50, consistent with their rights and psychosocial needs, has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. Refer to F-557, F-559, F-600, and F-745. The findings include: Review of the facility's policy titled, Care Plans - Comprehensive, dated 08/01/2013, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Per the policy, the Care Planning/Interdisciplinary Team developed and maintained a comprehensive care plan for each resident, in coordination with the resident, and his/her family or representative, that identified the highest level of functioning the resident could be expected to attain. Continued review revealed that the comprehensive care plan was based on a thorough assessment that included, but was not limited to, the Minimum Data Set (MDS) Assessments. Further review revealed the care plan would aid in preventing or reducing a decline in the resident's functional status and/or functional levels and would reflect currently recognized standards of practice for problem areas and conditions. Review of care plan interventions revealed they were implemented after consideration of the resident's problem areas and their causes. Additional review revealed the care plans were ongoing and revised as information about the resident and the resident's condition changed. Review of the facility's policy titled, Using the Care Plan, dated 08/01/2013, revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who had responsibility for providing care or services to the resident. Further review revealed that completed care plans were available to authorized personnel. Continued review revealed the nurse aide was responsible for reporting to the nurse or charge nurse any change in the resident's condition. Additional review revealed that changes in the resident's condition must be reported to the Nurse Assessment Coordinator, so that a review of the resident's assessment and care plan could be made. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a fifteen (15) of fifteen (15), which indicated intact cognition. Review of Resident #6's care plan, dated 11/23/2021, revealed a focus of psychosocial wellbeing risk related to new environment with interventions utilizing psychiatric services when needed and per the Physician's Orders. Further review of the care plan revealed a goal that the resident would have care needs met daily as measured by the resident being clean, well groomed and odor free. Interventions included staff assistance with dressing, hygiene, and oral and denture care daily and as needed. Interview with Resident #6, on 03/10/2022, revealed he/she did not receive any written notice prior to the facility's attempt to transfer him/her to another room. Further interview revealed Resident #6 refused to be transferred. The resident stated that housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6 to. According to Resident #6, he/she asked repeatedly for his/her belongings to be returned from 02/24/2022 until 02/28/2022, when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and he/she was distraught and cried daily. Further interview revealed Resident #6 stated, because his/her personal belongings had been taken away, he/she could not perform oral hygiene or change clothes from 02/24/2022 through 02/28/2022. Interview with State Registered Nurse Aide (SRNA) #18, on 03/15/2022 at 2:26 PM, revealed she worked the weekend Resident #6's belongings were removed. She stated staff could not provide care because the resident could not get a bath or change of clothes due to his/her hygiene supplies and clothing had been moved. Continued interview revealed staff members were informed they were not allowed to get Resident #6's belongings. Further interview revealed the staff determined the reason was that the Administrator was trying to get the resident to move to the other side of the building. She stated Resident #6 expressed sadness about the situation. Interview with SRNA #7, on 03/15/2022 at 2:50 PM, revealed she did not give care during the five (5) day time period. She stated staff was not allowed to get the resident's belongings from the other room. SRNA #7 stated the instruction, not to get the resident's belongings, came from the Administrator. Interview with SRNA #16, on 03/18/2022 at 7:47 AM, revealed she worked on the night shift of 02/24/2022. She stated that Resident #6 asked for his/her belongings, particularly pajamas. She stated the resident declined the offer of a hospital gown, and remained in his/her old clothing. Further review of Resident #6's medical record revealed there was no documented evidence his/her comprehensive care plan was implemented during 02/24/2022 through 02/28/2022. 2. Review of Resident #50's medical record revealed the facility admitted the resident, on 01/25/2021, with diagnoses of Morbid Obesity Due to Excess Calories, Generalized Anxiety Disorder, Fracture of Unspecified Parts of Lumbosacral Spine and Pelvis, Acute Kidney Failure, Chronic Kidney Disease Stage 3, and Non-ST Elevation Myocardial Infarction. Review of the Quarterly admission Minimum Data Set (MDS) Assessment, dated 01/04/2022, revealed, in the Cognitive Patterns section, a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #50's comprehensive care plan, dated 01/27/2022, revealed a focus for potential for grieving related to the death of a spouse, with interventions including staff to observe for causative and contributing factors that may delay the grief process and reduce or eliminate causative or contributing factors that may delay grieving, if possible. Further review revealed a focus for a potential problem with the resident's psychosocial well-being related to anxiety, depression, and pain. Continued review revealed to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Additional review of Resident #50's comprehensive care plan, dated 01/27/2022, revealed to increase communication between resident/family/caregivers about care and living environment: explain all changes, rules, and options. Also, to provide assistance/supervision/support to identify precipitating factor(s)/stressors, to reduce or eliminate causative and contributing factors, and to identify potential solutions to present problems. Continued review revealed focus for potential for mood problem related to depression, anxiety, and insomnia with interventions. Further review revealed to observe for the following: episode feelings or sadness. Observe for mood patterns, signs and symptoms of depression, anxiety, sad mood as per the facility's behavior monitoring protocols; observe mood to determine if problems seemed to be related to external causes, and provide encouragement/assistance/support to maintain as much independence and control as possible. Interview with Resident #50, on 03/12/2022 at 11:00 AM, revealed he/she did not receive any notice of a transfer on 02/07/2022. Resident #50 stated housekeeping staff came in and informed him/her of the transfer, and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse, who died in the room. Further review of Resident #50's medical record revealed there was no documentation that his/her comprehensive care plan was implemented, beginning with the room transfer on 02/07/2022. Interview with the Advanced Practice Registered Nurse (APRN), on 03/16/2022 at 2:45 PM, revealed when residents had dementia, they needed consistency and moving to another part of the facility could really disorient them. She stated increased behaviors and confusion could result from the disruption of routines. Interview with the Director of Nursing (DON), on 03/19/2022 at 11:59 AM, revealed she was told by the Housekeeping Supervisor that the Administrator told staff to leave Resident #6's personal belongings in the new room where he/she was supposed to be transferred. She stated this prevented Resident #6 from receiving daily hygiene and oral care due to lack of supplies and clean clothing. She stated charting on Resident #6 for Activities of Daily Living (ADL) indicated he/she refused a shower during the time of 02/24/2022 to 02/28/2022. She stated the resident might not have wanted to shower only to put the same clothes back on. The DON stated that this situation could be psychosocial harm, and she would be upset if it had happened to her. She stated her expectation was nurses and SRNA's would follow care plans, no matter what the circumstances. Interview with the Administrator, on 03/19/2022 at 9:35 AM, revealed she did forget about returning Resident #6's belongings to him/her, but staff could have retrieved his/her belongings. She further stated the goal was to keep residents safe and happy in their home. Further interview revealed she did not know whether anyone else followed up on the psychosocial impact of Resident #6 being without his/her belongings from 02/24/2022 to 02/28/2022. She stated she was unsure if the DON did or not and she did not remember if she talked to the APRN about harm or follow-up for Resident #6. The Administrator stated she was ultimately responsible to ensure policies, including residents' care plans, were followed. Interview with the Regional Clinical Operations Consultant, on 03/19/2022 11:21 AM, revealed her expectation was that clinical staff should be following residents' care plans, regardless of the circumstances. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents received written notice, including the reason for the room change/transfer, for eight (8) of fifty-three (53) sampled residents (Residents #6, #50, #72, #49, #3, #40, #60, and #82. The facility transferred Resident #6's personal belongings to another room, but when Resident #6 refused the transfer, the facility did not return the belongings for four (4) days. Resident #6 was upset and cried for four (4) days. The facility transferred Resident #50 out of a room the resident had shared with his/her spouse who had died in the room. The facility transferred Resident #72 several times who is a fall risk and has limited vision. The facility transferred Resident #49 who has Alzheimer's; the transfers caused confusion and behaviors. The facility transferred Resident #3 to another room. The move resulted in the resident having no social interactions with a roommate. The facility attempted to transfer Resident #40, who has Alzheimer's Disease, and felt his/her current room was his/her home. The facility transferred Resident #60 into a smaller room where the resident was more dependent on staff for ADL care and limited mobility to walk in the room. The facility transferred Resident #82, who has Alzheimer's Disease, to another room which caused increased behaviors. The facility's failure to ensure staff followed the facility's policy for transfers as well as Resident Rights, has caused or is likely to cause serious injury, serious harm, or death to residents. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's policy titled, Resident Rights H5MAPL0768, undated, revealed the resident had the right to refuse a transfer from a distinct part within the institution. Continued review revealed the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident was always treated with respect, kindness, and dignity. Review of the facility's policy titled, Transfers: Room to Room H5MAPL0792, dated 08/01/2013, revealed where feasible the facility would make room to room transfers when requested by the resident or as could become necessary to meet the resident's medical and nursing needs. Continued review revealed unless medically necessary or for the safety and well-being of the resident(s), a resident would be provided with an advance notice of the room transfer. Such notice would include the reason(s) why the move was recommended. It also stated the residents had a right to refuse a transfer from a distinct part within the facility. In addition, documentation of a room transfer would be recorded in the resident's medical record. Review of the facility's admission Agreement, under Patient Rights, undated, revealed the resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate was changed. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed he/she did not receive a written notice prior to the facility's attempt to transfer him/her to another room. Resident #6 stated he/she refused to be transferred. The resident stated housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6. Resident #6 stated he/she asked repeatedly for his/her belonging to be returned, from 02/24/2022 until 02/28/2022 when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and the resident was distraught and cried daily. 2. Review of Resident #50's medical record revealed the facility originally admitted Resident #50, on 09/17/2018 with diagnoses which included Nightmare Disorder, Insomnia, Hypertension, Depression, Anxiety, and Chronic Pain. Continued review of Resident #50's Quarterly MDS, dated [DATE], revealed the resident's BIMS score of fifteen (15) of fifteen, which indicated intact cognition. Interview with Resident #50, on 03/12/2022 at 11:00 AM, revealed he/she did not receive any notice of a transfer on 02/07/2022. Resident #50 stated housekeeping staff came in and informed him/her of the transfer and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse who died in the room. 3. Review of Resident #72's medical record revealed the facility admitted the resident, originally on 09/17/2019, with diagnoses which included Chronic Respiratory Failure, COPD, Atrial Fibrillation, Dementia, Congestive Heart Failure, Depression, Anxiety, and Osteoarthritis. Review of Resident #72's Quarterly MDS, dated [DATE], revealed a BIMS' score of five (5), which indicated severe cognitive impairment. Interview with Resident #72's POA/NOK, on 03/12/2022 at 10:10 AM, revealed he/she had never received any type of notice of the resident's transfers. The POA/NOK stated the resident had macular degeneration which caused sight limitations and would have to be re-oriented to the new rooms after the transfers. Review of the facility's Action Summary, dated 03/08/2022, revealed Resident #72 was transferred on 09/10/2021, 12/22/2021, 12/28/2021, 01/07/2022, 01/28/2022, 02/09/2022, 02/13/2022, 02/23/2022, 02/24/2022, and 03/23/2022. 4. Review of Resident #49's medical record revealed the facility originally admitted Resident #49, on 05/20/2021, with diagnoses which included Hypertension, Anxiety, and Dementia. Continued review of Resident #49's Quarterly MDS, dated [DATE], revealed the resident's BIMS score of five (5) of fifteen, which indicated severe cognitive impairment. Interview with Resident #49's POA (Power of Attorney)/Next of Kin (NOK), on 03/09/2022 at 11:10 AM, revealed the resident had Alzheimer's Disease, and the room transfers confused the resident and increased the resident's agitation. The POA/NOK stated he/she had never received a written notice nor, the reason for the transfers for Resident #49. 5. Review of Resident #3's medical record revealed the facility admitted the resident, on 01/31/2020, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Hypertension, and Multiple Sclerosis. Review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3's BIMS' score was fifteen (15) of fifteen, which indicated intact cognition. Interview with Resident #3, on 03/11/2022 at 9:50 AM, revealed he/she was moved from his/her room five (5) times in a period of five (5) months. Resident #3 stated he/she was notified right before the moves occurred, and he/she was pissed off because he/she should have gotten to one place and stayed. The resident stated COVID was the reason given for one (1) of the moves, but the resident could not recall the reasons for the other four (4) times he/she was moved. 6. Review of Resident #40's medical record revealed the facility admitted the resident, on 04/26/2021, with diagnoses which included Alzheimer's Disease, Assistance with Personal Care, Cerebrovascular Disease, Osteoarthritis, and Depression. Review of Resident #40's Quarterly MDS, dated [DATE], revealed under Section C - Cognition, severely impaired cognition. Interview with Resident #40's Spouse, on 03/10/2022 at 11:25 AM, revealed he/she had visited the resident on 02/14/2022. The following week, when he/she visited, the facility was in the process of transferring the resident to another room. The spouse stated he/she was not notified of the transfer and felt the Administrator was retaliating against the resident since he/she had complained, on 02/16/2022, about the resident being in soiled clothes and wearing the same clothes for two (2) days. The spouse stated Resident #40 had Alzheimer's Disease and was confused with room changes. 7. Review of Resident #60's medical record revealed the facility admitted the resident, on 01/14/2021, with diagnoses which included Congestive Heart Failure, Chest Pain, Atrial Fibrillation, and Hypertension. Review of Resident #60's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #60, on 03/12/2022 at 1:50 PM, revealed he/she never received any written notice or an explanation for the room transfers. Resident #60 stated his/her current room was smaller than his/her previous room. The resident stated this made self-ambulation harder to perform. The resident stated the bathroom was smaller, so staff had to take him/her to the shower room to provide personal hygiene. Resident #60 was moved three (3) times. Review of the facility's Action Summary, dated 03/08/2022, revealed Resident #60 was transferred to another room on 10/08/2021, 12/06/2021, and 12/22/2021. 8. Review of Resident #82's medical record revealed the facility admitted the resident, on 02/06/2021 with diagnoses which included Diabetes, Hypertension, Repeated Falls, Dementia, Depression, and Anxiety. Review of Resident #82's Quarterly MDS, dated [DATE], revealed the resident's BIMS score of nine (9) of fifteen (15), which indicated moderate cognitive impairment. Interview with Resident #82's POA/NOK, on 03/16/2022 at 3:45 PM, revealed the facility called him/her to inform him/her of the transfer of the resident to another room, on 10/14/2021. The POA/NOK stated the reason given was to be able to provide more monitoring of the resident since the room was across from the nurse's station. However, review of Resident #82's Psychiatric Nurse Practitioner's Note, from 10/28/2021, revealed the resident stated that he/she was stressed from just being there and in a bad mood due to having to change rooms. Record review revealed the resident required increased supervision for behaviors and suicidal ideation (sad and wanted to go home) during this period. Interview with the Administrator, on 03/15/2022 at 1:45 PM, revealed she was unaware of the regulation to give a resident a written notice prior to room transfer. The Administrator stated many of the transfers were to move residents onto the COVID unit after a breakout as well as moving residents off of the COVID unit. The Administrator also stated transfers were needed on the COVID unit since two (2) resident rooms shared a joint bathroom, and the transfers were needed to ensure the residents of the same sex were sharing a bathroom. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported the meals were better. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed she had worked at the facility for six (6) months and there had been in-services nearly every day. Continued interview revealed instruction/reminders were posted on the walls; and, kitchen staff had received training from a corporate contractor and a Dietary Manager (DM) from another facility. Interview on 03/31/2022 with [NAME] #2 at 10:10 AM; [NAME] #3 at 10:25 AM, and with DA #1 at 10:45 AM, all revealed they had received training on hand washing, gloves, food temperatures, dishwasher, on all the sanitizers; specifically training on holding temperatures for hot and cold foods, how to calibrate a thermometer, how to measure the temps of the food, including not touching the pan; food storage, including thawing meat on lowest shelf not above other foods; plating coverings; reading the tray cards for food preferences or specialty utensils/plates; watch for food dislikes and likes; and on the requirement to provide snacks to residents by Regional Dietary Manager (RD[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility's Social Services Director job description, it was determined the facility failed to provide medically-related social services related to the failure to advocate for residents and to assist them in the assertion of their rights. Residents were not assisted by the Social Services Director in voicing and obtaining resolution to grievances about treatment, living conditions, and accommodation of needs. Also, the Social Services Director did not provide services to meet the needs of residents who were coping with stressful events. This deficient practice affected eight (8) of fifty-three (53) sampled residents (Residents #3, #6, #40, #49, #50, #60, #72, and #82). The facility's failure to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident has caused or is likely to cause serious injury, serious harm, or death to a resident. Immediate Jeopardy was identified on 03/20/2022 and was determined to exist on 02/07/2022, in the areas of 42 CFR 483.10 Resident Rights, F-557 Respect, Dignity, and Right to have Personal Property at a Scope and Severity (S/S) of a J and F-559 Choose/Be Notified of Room/Roommate Change at a S/S of a K and Substandard Quality of Care (SQC); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 Free from Abuse and Neglect at a S/S of a J and SQC and F-609 Reporting of Alleged Violation at a S/S of a J and SQC; 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-656 Develop/Implement Comprehensive Care Plan at a S/S of a J; 42 CFR 483.40 Behavioral Health Services, F-745 Provision of Medically Related Social Service at a S/S of a K and SQC; 42 CFR 483.60 Food and Nutrition Services, F-812 Food Safety Requirements, at a Scope and Severity of an L; and 42 CFR 483.70 Administration, F835 Administration at a S/S of an L. The facility was notified of the Immediate Jeopardy (IJ) on 03/20/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, alleging removal of the IJ on 03/26/2022. The State Survey Agency determined the IJ had been removed on 03/26/2022, as alleged, prior to exit on 03/31/2022. The findings include: Review of the facility's job description, Social Services Director, undated, revealed the essential functions included: to ensure that all residents were given fair and equitable treatment, the freedom of self-determination and individuality, and the respect for privacy, property, and civil rights. Review of the facility's admission Agreement, Resident Rights, undated, revealed the resident(s) had the right to be free from mental and physical abuse. In addition, the resident had the right to retain and use personal possessions, including furniture, and clothing, as space permitted. Further, the resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Interview with the Administrator, on 03/13/2022 at 11:05 AM, revealed it was the responsibility of the Social Services Director to inform the residents and/or their POA/NOK (Power of Attorney/Next of Kin) when a room transfer was warranted. The Administrator stated the Social Services Director (SSD) was responsible for documentation in the medical record when the notification of a room transfer was given. Also, she stated it was the responsibility of the SSD to follow up with the resident(s) after a transfer and document their emotional well-being after the transfer. 1. Review of Resident #6's medical record revealed the facility admitted the resident, on 08/10/2021, with diagnoses which included Vertebra Fracture, Dementia, Depression, and Anxiety. Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #6, on 03/10/2022 at 10:30 AM, revealed he/she did not receive any written notice prior to the facility's attempt to transfer him/her to another room. Resident #6 stated he/she refused to be transferred. The resident stated housekeeping staff removed all of his/her personal belongings from the current room and moved them to the room the facility intended to transfer Resident #6. Resident #6 stated he/she asked repeatedly for his/her belongings to be returned, from 02/24/2022 until 02/28/2022 when the personal belongings were returned. Resident #6 stated he/she told staff this was abusive, and he/she was distraught and cried daily. Continued review of Resident #6's medical record, in the Social Service Notes, revealed no documentation related to the resident being without his/her belongings from 02/24/2022 to 02/28/2022. Additionally, there were no interventions by Social Services to address Resident #6's psychosocial needs. 2. Review of Resident #49's medical record revealed the facility originally admitted Resident #49, on 05/20/2021, with diagnoses which included Hypertension, Anxiety, and Dementia. Review of Resident #49's Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be five (5) of fifteen, which indicated severe cognitive impairment. Interview with Resident #49's POA (Power of Attorney)/Next of Kin (NOK), on 03/09/2022 at 11:10 AM, revealed the resident had Alzheimer's Disease, and the three (3) room transfers confused the resident and increased the resident's agitation. The POA/NOK stated he/she had never received a written notice, or the reason for the transfers for Resident #49. Continued review of Resident #49's medical record, in the Social Service notes, revealed no documentation that the SSD assessed the resident's psychosocial needs related to the resident's three (3) room transfers. 3. Review of Resident #40's medical record revealed the facility admitted the resident, on 04/26/2021, with diagnoses which included Alzheimer's Disease, Assistance with Personal Care, Cerebrovascular Disease, Osteoarthritis, and Depression. Review of Resident #40's Quarterly MDS, dated [DATE], revealed under Section C - Cognition, severely impaired cognition. Interview with Resident #40's Spouse, on 03/10/2022 at 11:25 AM, revealed he/she had visited the resident on 02/14/2022. The following week, when he/she visited, the facility was in the process of transferring the resident to another room. The spouse stated he/she felt the moves were harmful for the resident because he/she had Alzheimer's Disease and was confused with room changes. Continued review of Resident #40's medical record revealed there was no documentation in the Social Service notes that the SSD assessed the resident's psychosocial needs related to the move. 4. Review of Resident #3's medical record revealed the facility admitted the resident, on 01/31/2020, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Hypertension, and Multiple Sclerosis. Review of Resident #3's Quarterly MDS, dated [DATE], revealed the facility assessed Resident #3's BIMS score as fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #3, on 03/11/2022 at 9:50 AM, revealed he/she was moved from his/her room five (5) times in a period of five (5) months. Resident #3 stated he/she was notified right before the moves occurred, and he/she was pissed off because he/she should have gotten to one place and stayed. Resident #3 stated he/she was angry about the move and lacked the social interaction he/she had in his/her previous room. Resident #3 stated he/she wanted to return to his/her original room. Continued review of Resident #3's medical record revealed there was no documentation in the Social Service Notes following the transfers, and no documentation that the SSD assessed the resident's psychosocial needs. 5. Review of Resident #72's medical record revealed the facility admitted the resident, originally on 09/17/2019, with diagnoses which included Chronic Respiratory Failure, Atrial Fibrillation, Dementia, Congestive Heart Failure, Depression, Anxiety, and Osteoarthritis. Review of Resident #72's Quarterly MDS, dated [DATE], revealed a BIMS' score of five (5), which indicated severe cognitive impairment. Interview with Resident #72's POA/NOK, on 03/12/2022 at 10:10 AM, revealed the resident had macular degeneration which caused sight limitations and made him/her at risk for falls. The POA/NOK stated the risk for falls and injuries increased because he/she would have to be re-oriented to the new room after each transfer. The POA/NOK stated the resident had been moved numerous times. Review of the facility's Action Summary, dated 03/08/2022, revealed Resident #72 was transferred to another room on 09/10/2021, 12/22/2021, 12/28/2021, 01/07/2022, 01/28/2022, 02/09/2022, 02/13/2022, 02/23/2022, and 02/24/2022. Continued review of Resident #72's medical record, in the Social Service notes, revealed no documentation that the SSD assessed the resident's psychosocial needs following the resident's numerous transfers. 6. Review of Resident #60's medical record revealed the facility admitted the resident, on 01/14/2021, with diagnoses which included COPD, Congestive Heart Failure, Chest Pain, Atrial Fibrillation, and Hypertension. Review of Resident #60's Quarterly MDS, dated [DATE], revealed the facility assess the resident to have a BIMS' score of fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #60, on 03/12/2022 at 1:50 PM, revealed he/she never received any written notice or the explanation for the several room transfers and was not happy about the moves. Resident #60 stated his/her current room was smaller than his/her previous room. The resident stated this made self-ambulation harder to perform. The resident stated the bathroom was smaller, so staff had to take him/her to the shower room to provide personal hygiene. Review of the facility's Action Summary, dated 03/08/2022, revealed Resident #60 was transferred three (3) times; 10/08/2021, 12/06/2021, and 12/22/2021. Continued review of Resident #60's medical record, in the Social Service note, revealed no Social Service documentation related to the transfers, and no documented evidence the SSD addressed Resident #60's needs. 7. Review of Resident #50's medical record revealed the facility originally admitted Resident #50, on 09/17/2018, with diagnoses which included Nightmare Disorder, Insomnia, Hypertension, Depression, Anxiety, and Chronic Pain. Review of Resident #50's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was fifteen (15) of fifteen (15), which indicated intact cognition. Interview with Resident #50, on 03/12/2022 at 11:00 AM, revealed he/she did not receive any notice of a transfer on 02/07/2022. Resident #50 stated housekeeping staff came in and informed him/her of the transfer and started taking items off the walls and packing up his/her personal belongings. Resident #50 stated he/she became very upset and cried all day long, increasing the resident's anxiety and depression due to the transfer. Resident #50 stated he/she did not want to move out of the current room since he/she had shared the room with his/her spouse who died in the room. Continued review of Resident #50's medical record, in the Social Service notes, revealed no documentation of the SSD's assessment of the resident's psychosocial needs related to the room transfer. 8. Review of Resident #82's medical record revealed the facility admitted the resident, on 02/06/2021, with diagnoses which included Diabetes, Hypertension, Repeated Falls, Dementia, Depression, and Anxiety. Review of Resident #82's Quarterly MDS, dated [DATE], revealed the resident had a BIMS' score of nine (9) of fifteen (15), which indicated moderate cognitive impairment. Interview with Resident #82's POA/NOK, on 03/16/2022 at 3:45 PM, revealed the facility called him/her to inform him/her of Resident #82's transfer to another room, on 10/14/2021. The POA/NOK was told the transfer was to provide more monitoring of the resident since the room was across from the nurse's station. However, additional review of Resident #82's medical record revealed the Psychiatric Nurse Practitioner's Note, from 10/28/2021. Further review of the Note revealed the resident stated that he/she was stressed from just being there and in a bad mood due to having to change rooms. Record review revealed the resident required increased supervision for behaviors and suicidal ideation during this period. Continued review of Resident #82's medical record, in the Social Service notes, revealed no SSD documentation of an assessment following the resident's transfers. Interview with the former Social Services Director, on 03/10/2022 at 9:35 AM, revealed she did rounds of the residents after the transfers, but she was directed by the Administrator not to put any documentation in the residents' medical records. The former Social Services Director stated she told the Administrator many of the residents were unhappy and upset with the transfers, but the Administrator took no action regarding these concerns. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/27/2022, that alleged removal of the Immediate Jeopardy (IJ) on 03/26/2022. The facility implemented the following: 1. Resident #6's personal belongings were returned to his/her room on 02/28/2022 by the Environmental Services Director at the direction of the Administrator. Licensed Mental Health Counselor, a master's prepared Social Services Director at a sister facility, performed a Patient Health Assessment-9 (PHQ-9) on Resident #6, on 03/21/2022. This assessment was to determine if Resident #6 had experienced any change in status because of the room move; to ensure staff were treating the resident with respect and dignity; and, see if the resident had any social service needs. No concerns were noted. Resident #49 and his/her Power of Attorney (POA)/Next of Kin (NOK), Resident #50 and his/her POA/NOK, Resident #40 and his/her POA/NOK, Resident #3 and his/her POA/NOK, Resident #72 and his/her POA/NOK, Resident #60 and his/her POA/NOK, and Resident #82 and his/her POA/NOK were contacted by the Licensed Mental Health Counselor, on 03/21/2022, to ensure they were satisfied with their current room. The counselor also checked to ensure if the residents had all their belongings, and to determine if the residents had any social services needs. Interview with the residents and the mental health counselor, on 03/21/2022, revealed no psychosocial changes. 2. The Administrator was no longer employed, at the facility, effective 03/20/2022. The Regional Director of Operations (RDON) will continue to ensure the facility is administered effectively and efficiently to attain and maintain the highest practicable physical, mental, psychosocial well-being of the residents as part of the facility's governing body. Along with the Regional Clinical Operations Consultant, the RDON will efficiently oversee and ensure the appropriate plans of action are in place to correct quality deficiencies. 3. The Minimum Data Set (MDS) Support Nurse conducted PHQ-9 assessments and interviews to determine satisfaction of all residents and responsible parties, who had experienced a room transfer since 01/01/2022 to determine if the residents' belongings were moved with the resident to their new room on 03/21/2022 and 03/22/2022. No areas of concern were identified. Interviews conducted with residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or higher were conducted by a Licensed Social Worker from a sister facility, on 03/25/2022, to determine if all residents felt safe; if they were treated with respect and dignity; or, if they had any social service needs. No concerns were identified. 4. The Regional Clinical Operations Consultant and/or the Regional Director of Operations completed reeducation with the Director of Nursing (DON), on 03/23/2022, regarding dignity and respect, per the facility's policy. The reeducation included moving all the residents' belongings when a resident was moved to another location in the center. Further reeducation regarding the resident's right to receive written notice, including the reason for the room change before the resident's room or roommate was changed. Education included the resident's right to refuse a room change as well. The DON reeducated the Assistant Directors of Nursing (ADON), on 03/23/2022, on Resident Rights which included moving all the resident's belongings when a resident was moved to another location in the center, and that a resident was to be given a written notice prior to a room transfer. A post-test was given to validate understanding. On 03/23/2022, the DON and the ADONs, reeducated the housekeeping staff and nursing staff (licensed and unlicensed) on dignity and respect per the facility's policy to include moving personal belongings with the resident and the resident's right to refuse a room change. The DON and ADONs conducted reeducation on all staff (licensed and unlicensed) regarding the abuse policy and the reporting requirements of suspected abuse on 03/22/2022 and 03/23/2022. The reeducation included the resident had the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, free from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Additionally, the reeducation included the reporting requirements of suspected abuse and at no time were goods and services to be withheld from a resident to include personal belongings. Additional reeducation regarding the expectation of a resident's care plan to be followed, including hygiene and oral care. A post-test was given at the time of the reeducation to validate understanding. All staff (licensed and unlicensed) were reeducated on the compliance hotline, as additional option to report suspected abuse, neglect, etc. The hotline is available 24/7/365 days a year and can be used anonymously; the hotline number was posted throughout the facility on 03/24/2022. Staff were also made aware of the RDO's phone number; the RDO's phone number was posted on 03/24/2022 in multiple locations throughout the building. The education was provided by the DON, ADONs, Staffing Coordinator, and the MDS Support Nurse. 5. All staff not available during the time of the reeducation, including agency staff, will receive education by the DON or ADONs to include a post-test upon the day of return to work prior to working the shift. New hires will receive the education during orientation. Any newly hired Administrator, Social Services Director, and/or admission Director will be provided education and a post-test during orientation. 6. The facility developed a Room Change Form. Any potential room change will be discussed with the Intra-Disciplinary Team (IDT) which included the DON, ADONs, Administrator, Social Services Director, and the admission Director. If the IDT approves, the admission Director will proceed and ensure that all belongings are moved. The IDT will review the Room Change Form at the next meeting to ensure all room moves were handled per facility policy. If a room change was emergent and after hours, the nurse will contact the Administrator, DON, or Admissions Director for approval. If approved, the Room Change Form will be completed and reviewed by the IDT at its next meeting. 7. The DON, ADON's, Staffing Coordinator, Central Supply Coordinator, and/or licensed nurse conducted audits of all room moves to determine if the resident's belongings were sent with each room change for thirty (30) days. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse conducted visual observation rounds to determine if good/services were provided, and that the residents had no concerns related to abuse daily until removal of the immediate jeopardy; these audits will be presented to the QAPI meeting daily. The DON, ADONs, staffing coordinator, central supply coordinator, and/or licensed nurse will question/interview five (5) employees on random shifts daily to determine understanding and reporting abuse. All residents will be assessed for seventy-two (72) hours post room change for adjustment and satisfaction related to room transfers by either the Social Services Director (Social Worker from a sister facility) or Licensed Nurse. The care plan will be updated with room changes to provide care related to the room change. 8. A new Dietary Director was hired on 03/21/2022. The facility contracted with a dietary consulting company, on 03/14/2022 to provide on-site food services consulting for up to six (6) weeks. The consulting company will be utilized to assist in the training of the new dietary manager to include storage, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Regional Director of Operations (RDO) has had dietary managers from other buildings come to the facility to provide support and training for staff daily. The facility-initiated food handling course through efoodhandlers, approved by the local County Health Department, beginning on 03/16/2022 and completion by 03/24/2022. Any new hire will receive the education during general orientation. 9. Food temperature logs, observation of staff taking the temperature of food with each meal and food storage will be audited daily by the Dietary Manager (from sister facility). The results of these daily audits will be given to the Administrator and presented to the QAPI (Quality Assurance and Performance Improvement) Committee daily. 10. The Regional Director of Operations (RDO), Social Services Director (SSD), the DON, and/or the ADONs will report the review findings of the above audits daily to the Quality Assurance and Performance Improvement Committee which consists of the Administrator, DON, ADON, Admissions Coordinator, the Medical Director, and the Staffing Coordinator. 11. The Regional Director of Operations and Regional Clinical Operations Consultant discussed the potential plans of correction, on 03/22/2022, with the Medical Director to develop an IJ Removal Plan. The QAPI Committee met on 03/24/2022 and 03/25/2022 to review all education, interventions, and audits. The QAPI Committee will meet daily until the Immediate Jeopardy has been removed. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed she was the previous Environmental Services Director and she had Resident #6's personal belongings returned to the resident on 02/28/2022. Review of Resident #6's medical record, on 03/31/2022, revealed the Patient Health Assessment-9 (PHQ-9) was completed as well as documentation by the Licensed Mental Health Counselor. Review of Resident #49, Resident #50, Resident #40, Resident #3, Resident #72, Resident #60, and Resident #82's medical record revealed documented interviews with either the resident or their next of kin by the Licensed Mental Health Counselor. Interview with Resident #6, on 03/31/2022 at 9:30 AM, revealed he/she had spoken to the Licensed Mental Health Counselor regarding his/her belongings being moved out of the room. No concerns were noted. 2. Interview with the Regional Director of Operations (RDO) and the Interim Administrator, on 03/30/2022 at 2:53 PM, revealed the previous Administrator was terminated on 03/20/2022. The RDO/Interim Administrator provided documentation of his referral to the Kentucky Board of Licensure for Long Term Care Administrators related to the previous Administrator's actions. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed things were going smoother since the Administrator left, and stated the general feeling of staff was less tense. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the general feeling with staff and residents was better recently. Interview with the Maintenance Technician, on 03/30/2022 at 4:13 PM, revealed things were 100% better since the Administrator left; in the last two weeks, communication was way better for maintenance now; staff seemed much happier and were willing to be at work since the Administrator was gone. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed residents and staff seemed in better spirits, staff having a better day helps residents have a better day also. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed residents seemed less tense lately and staff were less tense last week with the Administrator change. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed the atmosphere of the staff was like a weight had been lifted; residents seemed stressed and tense before and this has improved, and there were more residents participating in activities. Interview with Dietary Aide (DA) #3, on 03/31/2022 at 9:48 AM, revealed the atmosphere was so much better and staff were less on edge. Interview with the Activities Director, on 03/31/2022 at 3:14 PM, revealed the mood among the staff and residents was much better, like a burden had been lifted from their shoulders. She stated more residents had been coming to activities recently. 3. Review of clinical records, with dates beginning on 03/30/2022, revealed PHQ-9 assessments and documentation of interviews of all residents' charts, who had experienced a room transfer since 01/01/2022. Interview with the MDS Support Nurse, on 03/31/2022 at 11:34 AM, revealed she had completed all the PHQ-9 on residents, who had experienced a transfer within the facility since 01/01/2022 until the present on 03/22/2022. 4. Interview with the Regional Director of Operations (RDO)/Interim Administrator and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed they had provided education to the DON regarding Patient Rights, Abuse, Transfers, as well as reporting Abuse on 03/23/2022. Interview with the DON, on 03/31/2022 at 10:45 AM, revealed the RDO and RNC provided her with the documented education and, she in turn, provided the information to the ADONs. They then started the education with the rest of the staff to ensure compliance with regulations. The DON stated she was working with the HR Manager to ensure all staff members received the required education. Interviews on 03/30/2022 and 03/31/2022 with the MDS Coordinator at 3:38 PM, SRNA #8 at 3:50 PM, LPN #13 at 4:02 PM, LPN #5 at 4:07 PM, Maintenance Technician at 4:13 PM, Laundry Aide at 4:32 PM, LPN #7 at 4:45 PM, SRNA #9 at 4:50 PM; on 03/31/2022 with Dietary Aide (DA) #3 at 9:48 AM, Dietary Manager (RDM) at 10:28 AM, and the Activities Director at 3:14 PM revealed they had all received training about residents' rights, abuse, de-escalation, reporting abuse, care planning, social services, administration (specifically reporting abuse to administrator or above to compliance hotline or state, on room transfers, that residents' belongings should be moved, and about respect and dignity. They further revealed the leadership was rounding and quizzing them on recent education issues. 5. Interview with the Human Resource (HR) Manager, on 03/31/2022 at 2:52 PM, revealed the staff had a lot of education and she was keeping a master list to ensure all staff received all the education required before starting their shift. The DON, ADONs, and other Directors/Managers were kept up to date with which staff needed to take the required education and training and complete a posttest prior to working, by the HR Manager. 6. Interview with the Regional Director of Operations (RDO) and Interim Administrator, Admissions Coordinator (AC), and Regional Nurse Consultant (RNC), on 03/30/2022 at 2:53 PM, revealed the facility developed a Room Change Form/procedure. Prior to a room transfer, staff would obtain permission from the resident and/or POA with a witness. Further interview revealed they would document it on the designated form, and either email (electronic mail), fax or text so that written notice was given, and then the form would be signed. If the resident refused, that would also be documented. They stated this was discussed by the Interdisciplinary Team (IDT). 7. Interview with the RNC, on 03/30/3022 at 2:53 PM, revealed leadership was conducting random rounding per the audits described in the IJ Removal Plan. The RDO/Administrator stated they used audit sheets for rounding. She stated there were multiple audit sheets to cover different areas. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed that the Corporate MDS Support Nurse was involved in reassessing residents after room transfers. Continued interview revealed residents were monitored for seventy-two (72) hours post transfer. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed with transfers, she was responsible for updating care plans with specific goals within the psychosocial focus. The MDS Coordinator stated she added care plan elements for acute issues, then documented that a particular acute issue was resolved from the care plan. She stated every resident, who had been transferred, had their care plan updated, by her or the MDS Support Nurse. Interview with SRNA #8, on 03/30/2022 at 3:50 PM, revealed residents were on 72-hour monitoring after they were moved or at admission to make sure they were not depressed or sad. SRNA #8 also stated leaders were rounding and asking staff about issues such as abuse and other things. Interview with LPN #5 on 03/30/2022 at 4:07 PM, revealed leadership was rounding and asking about the issues; care plans were being updated; and residents were being assessed for 72 hours post transfer. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed that nursing maintained 72-hour acute monitoring after a room transfer and leaders were rounding and asking questions about the training issues. 8. Interview with the Regional Director of Operations (RDO)/Interim Administrator, on 03/30/2022 at 2:53 PM, revealed a new Dietary Manager was hired and was currently in training. The RDO stated he had brought in a consulting company, for a six (6) week period, to help with training the dietary/kitchen staff, as well as having the Regional Dietary Manager and Dietary Managers from sister facilities to come to the facility to help with the training and auditing to ensure compliance with food regulations. Interview with the MDS Coordinator, on 03/30/2022 at 3:38 PM, revealed she had received training on a lot of dietary issues including snacks; snacks coming out at 10:00 AM, 2:00 PM and 8:00 PM; diabetics needed more protein at bedtime, including having more substantial snacks offered for diabetics, also extra snacks maintained for everybody. Interview with State Registered Nursing Assistant (SRNA) #8, on 03/30/2022 at 3:50 PM, revealed the facility's food was a lot better; snacks came regularly, and nourishment rooms were well stocked with different snacks and drinks. Interview with LPN #5, on 03/30/2022 at 4:07 PM, revealed the residents were reporting the food was much better. Interview with a Laundry Aide, on 03/30/2022 at 4:32 PM, revealed food has been much better, residents had commented on improved food and when she helped pick up trays, she has noticed increased consumption. She said she had observed snacks being distributed since the survey. Interview with LPN #7, on 03/30/2022 at 4:45 PM, revealed the food looked better. She stated stated snacks were now coming out at 10:00 AM and 2:00 PM on her shift and the nourishment rooms were better stocked. Interview with SRNA #9, on 03/30/2022 at 4:50 PM, revealed multiple residents had reported t[TRUNCATED]